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AUTHORIZED AGENT AFFIDAVIT I rtejt- �e�`� hereby grant authorization tol`,�OM v►Lv1 (Contractor) 1 (Authorized Agent) to act in my behalf with the Hernando County Building Division while conducting activities related to obtaining permits. These activities specifically include signing all documents requiring signature of"contractor". VvtLI�LGt� L�d_s to be considered an agent of my business and (Authorized Agent) therefore the signature of said agent is binding and causes me to assume all responsibilities connected to or associated with the signature as they may relate to my contracting business. rIP I rzf1,1 Nff Vi relieve the Hernando County Building of, (Contractor) and agree to hold the Hernando County Building Division harmless from, any and all responsibility, claims . ing from or related to the Division's acceptance of the above agent's sign for permit-related a ities. I further understand that it is my sole responsibility to grant and a minate an uc aut -arid o ensure that the Division receives timely notice of any t e a ' V__ gnat of o ct t Signature of Agent e AC. M 5-1, State Certification or Registration Number County Certification Number(if applicable) **PLEASE NOTE: BOTH SIGNATURES MUST BE NOTARIZED** Notary for Contractor's Signature: Notary for Agent's Signature: State of (,C1 County of Lmn State of 1D,D6 County of L rpQd0Q The foregoing.was acknowledged before me this 1 12> The foregoirig was acknowledged before me this day of r, _,by�� d of , 00 ,by who is personally known l who is personally known to me,or ttb me, rwho produced as who produced as identi ation. Identific t]on. Notary I? turENotary Public State of Florida Notary Pub] Melissa Brown Melissa Brown My Commission GG 204483 My Commission GG 204483 �M1 Expires 04/08/2022 �i Ex ire Print,Ty ' r f Print,Type, a *The original of this affidavit should be kept in the possession of the above designated"Authorized Agent". This affidavit need only be produced to Hernando County when signing documents in the presence of a permit representative. When you sign a permit application be prepared to produce this affidavit, it will be copied and placed in the appropriate permit application.* **The Division,at its discretion,may require a contractor or license-holder to personally apply for or obtain a building permit notwithstanding any authorization allowing another person to apply for or obtain any permit on behalf of a contractor,qualifier,or license-holder. _ Revised 10/2015 contauth.sop